Healthcare Provider Details

I. General information

NPI: 1679514392
Provider Name (Legal Business Name): BERNARD H AGNEW FNP
Entity Type: Individual
Gender: Male
Sole Proprietor: N

II. Dates (important events)

Enumeration Date: 06/10/2006
Last Update Date: 03/15/2023
Certification Date: 03/15/2023
Deactivation Date:
Reactivation Date:

III. Provider practice location address

1481 HWY 40 E
KINGSLAND GA
31548-6507
US

IV. Provider business mailing address

3023 ALBACORE CIR
SILVERDALE WA
98315-9780
US

V. Phone/Fax

Practice location:
  • Phone: 860-287-0738
  • Fax:
Mailing address:
  • Phone: 360-535-7080
  • Fax:

VI. Provider taxonomy

Scope of Practice (Provider specialty)

# 1
Primary TaxonomyY
Taxonomy Code363LF0000X
TaxonomyFamily Nurse Practitioner
License NumberRN283456
License Number StateGA
# 2
Primary TaxonomyN
Taxonomy Code1710I1002X
TaxonomyIndependent Duty Corpsman
License Number
License Number State

VIII. Authorized Official

Name:
Title or Position:
Credential:
Phone: